A home health nurse is assessing a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following actions should the nurse take next?
Reinforce the importance of daily weights.
Call the health care provider for further instructions.
Document the findings and continue with the visit.
Ensure the client has been taking their prescribed diuretic.
The Correct Answer is D
A. Reinforce the importance of daily weights. While reinforcing the importance of daily weights is crucial for managing heart failure, it does not address the immediate concern of the patient's weight gain and edema. The nurse needs to take a more direct action to manage the patient's current condition.
B. Call the health care provider for further instructions. Calling the health care provider is a reasonable step, but it may delay immediate intervention that the nurse can perform. Ensuring the patient is taking their prescribed diuretic can provide more immediate relief from fluid retention.
C. Document the findings and continue with the visit. Documenting the findings is necessary for accurate medical records, but it does not address the urgent need to manage the patient's symptoms. Immediate action is required to prevent further complications.
D. Ensure the client has been taking their prescribed diuretic. Ensuring the patient has been taking their prescribed diuretic is the most appropriate immediate action. Diuretics help reduce fluid buildup, which can alleviate the weight gain and edema, providing quick relief and preventing further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
A. This response dismisses the client's concerns and does not address the underlying issue.
B. This response is appropriate, but it does not address the underlying issue of altered taste perception.
C. This response suggests a solution but does not address the underlying issue of altered taste perception.
D. This response acknowledges the client's concerns and provides an explanation for the altered taste perception, which can be reassuring and informative.
Correct Answer is B
Explanation
A. Fentanyl, an opioid, typically causes pupillary constriction, not dilation. This is known as miosis.
B. Fentanyl can cause bradycardia or tachycardia, but tachycardia is more common in acute toxicity.
C. Fentanyl is more likely to cause hypotension (low blood pressure) rather than hypertension (high blood pressure).
D. Fentanyl can cause respiratory depression, leading to hypoventilation and possibly bradypnea or apnea, but tachypnea (rapid breathing) is less likely to occur as a direct effect of fentanyl toxicity.
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